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However erectile dysfunction causes agent orange purchase genuine levitra soft on-line, high incidence of side effects and risk of thrombo-embolism limit their prolonged use erectile dysfunction va benefits best levitra soft 20 mg. These drugs exert an antioestrogenic effect and their continuous administration causes decidualization and endometrial atrophy. This hormone does not prevent ovulation and is suitable for a woman trying to conceive. Danacrine, an anabolic drug does not cause menopausal symptoms, as E2 level does not drop below 50 pg/mL. The progesterone levels rises in 15 min, peaks in a few hours and stabilizes thereafter. It is ideal to relieve pain and menorrhagia in premenopausal women who have completed their families. Danazol, a synthetic derivative of ethinyl testosterone, inhibits pituitary gonadotropins. It is contraindicated in liver dysfunction and pregnancy should be avoided as it is teratogenic. Recently, danazol is implicated in the development of ovarian cancer, and many gynaecologists are now reluctant to use this drug. Gestrinone is a 19-nortestosterone derivative similar in action to danazol, but it has fewer side effects and is long-acting. Other antiprostaglandin and antiinflammatory (nonsteroidal) drugs like naproxen are also useful. To avoid this, add-back therapy with progestogens and tibolone or etidronate is recommended. Minimal Invasive Surgery Since hormones delay pregnancy, primary surgery is preferred in infertile women. Recent advances in gynaecology have introduced laparoscopy in the management of pelvic endometriosis in young women. This offers the advantages of conserving the ovaries and the fallopian tubes, and improving fertility. Superficial lesions are easier to destroy and yield better fertility results than the deep implants. Laser has the advantage of controlling the depth of destruction by adjusting the power density. It avoids ovarian destruction with peeling off of the cyst wall, but recurrence is slightly high. Role of surgery n Failed medical therapy n Infertility n Recurrence n Chocolate cyst ovary the consensus of opinion is that cystectomy is more beneficial in extent of pain relief, longer recurrence time and longer pain-free intervals. However, the excision of the cyst wall deprives the patient of potential ova and thereby reduces her fertility potential. Laparoscopic breaking of adhesions in the pelvis relieves dysmenorrhoea and pelvic pain. Pregnancy rate following conservative surgery is 40%, 50% and 70% in severe, moderate and mild endometriosis, respectively. It is advisable to postpone laparoscopic technique for 3 months if hormone therapy has already been given, to avoid under diagnosis. Postoperative medical therapy to deal with the residual tissue and prevent recurrence.
With greater degrees of obstruction erectile dysfunction treatment heart disease buy levitra soft with paypal, this responseisinadequate erectile dysfunction in diabetes treatment order levitra soft with paypal,andthecoronaryflowreserveaffordedbyR2vasodilationis insufficienttomeetoxygendemand. Zones of tissue with marginal blood flow may develop that areatriskformoreseveredamageiftheischemicepisodepersistsorbecomesmore severe. Nonischemic areas of myocardium may compensate for severely ischemic andborderzonesofischemiabydevelopingmoretensionthanusualinattemptto maintaincardiacoutput. Unalterableriskfactorsincludegender,age,familyhistoryorgeneticcomposition, environmental influences, and, to some extent, diabetes mellitus. Alterable risk factors include smoking, hypertension, hyperlipidemia, obesity, sedentary lifestyle, hyperuricemia, psychosocial factors such as stress, and use of drugs that may be detrimental(eg,progestins,corticosteroids,calcineurininhibitors). Cardioselective -blockers may minimize adverse effects such as bronchospasm,intermittentclaudication,andsexualdysfunction. Thehalf-lifeofnitroglycerinis1to5minutesregardless of the route, hence the potential advantage of sustained-release and transdermal products. Dosing of long-acting preparations should be adjusted to provide a hemodynamic response. Lifestyle modifications include daily physical activity, weight management,dietarytherapy,smokingcessation,psychologicalinterventions,limitationof alcoholintake,andmanagementofbloodpressureanddiabetes. For patients who do not tolerate statins, a bile acid sequestrant, niacin, or both is reasonable. If blood pressure is 140/90 mm Hg or higher, drug therapy should be instituted in addition to or after lifestyle modifications. Medical Therapy for Relief of Symptoms Sublingual nitroglycerin or nitroglycerin spray for immediate relief of angina. Long-acting nondihydropyridine calcium antagonists (verapamil, diltiazem) instead of a -blocker as initial therapy. Ranolazine can be useful as a substitute for -blockers if initial treatment with -blockers causes unacceptable adverse effects or is ineffective or contraindicated. Ranolazine combined with a -blocker can be useful when initial -blocker treatment is unsuccessful. Level of Evidence: A = Data derived from multiple randomized clinical trials with large numbers of patients. B = Data derived from a limited number of randomized trials with small numbers of patients, careful analyses of nonrandomized studies, or observational registries. The use of bile acid sequestrant is relatively contraindicated when triglycerides are 200 mg/dL and is contraindicated when triglycerides are 500 mg/dL. Dietary supplement niacin must not be used as a substitute for prescription niacin. Nitroglycerin spray may be useful when inadequate saliva is produced to rapidly dissolve sublingual nitroglycerin or if a patient has difficulty opening the tablet container. Nifedipine, verapamil, and diltiazem are all equally effective as single agents for initial management. Once patients have been optimized on medical therapy, symptoms should improveover2to4weeksandremainstableuntilthediseaseprogresses. Itcanbeprecipitated by hemorrhage; burns; trauma; surgery; intestinal obstruction; and dehydration from considerable insensiblefluidloss, overaggressivediureticadministration,and severe vomiting or diarrhea. Relative hypovolemia leading to hypovolemic shock occursduringsignificantvasodilation,whichaccompaniesanaphylaxis,sepsis,and neurogenicshock. Atthispoint,tissueO2requirements have been satisfied, and further increases in Do2 will not alter Vo2 (flow independency). However, studies in critically ill patients show a continuous, pathologic dependencerelationshipofVo2withDo2. If fluid administration does not achieve desired end points, pharmacologic supportisnecessarywithinotropicandvasoactivedrugs.
The drugs used are as follows: n n Extravasation should be avoided by using angiocatheter when giving doxorubicin erectile dysfunction 2015 purchase levitra soft online now, actinomycin-D and vincristine erectile dysfunction drugs history order 20mg levitra soft with mastercard. Breast Cancer Although tamoxifen improves the survival period, it causes endometrial hyperplasia and cancer, and requires regular monitoring with ultrasound study of endometrium and endometrial biopsy. The gynaecologist should be aware of the limitations of chemotherapy as well as its effectiveness. Tumour markers should be employed during chemotherapy to watch the effectiveness and decide the duration of chemotherapy in an individual case. Cisplatin causes nausea, renal failure, peripheral neuropathy, myelosuppression, but no alopecia. Taxol derived from the bark of Pacific yew tree is in short supply, so it is expensive and available in semisynthetic form. The best results are obtained if the tumour size is initially reduced by surgery, chemotherapy or radiation. Immunotherapy includes: n n n n n n Vaccine against human papilloma virus for cancer cervix (prophylactic). Cisplatin/carboplatin with paclitaxel is the first line of chemotherapy treatment in advanced cancer. In ovarian cancer, chemotherapy is used as n n n Key Points n n n n Neoadjuvant therapy Concomitant therapy Adjuvant therapy n Neoadjuvant (before surgery or radiotherapy) the drug shrinks the tumour, reduces micrometastasis. Concomitant therapy (during treatment) acts as radiosensitizer, and enhances radiotherapy effect, but increases toxicity (Table 41. Adjuvant therapy (drugs mentioned above) is employed following surgery or radiotherapy but response to local residual/recurrence is low, because of poor vascularity of the tumour. The distal metastasis however responds better to adjuvant chemotherapy, because of its intact vascularity. With so many new drugs becoming available, tissue sensitivity test to various drugs may improve our decision regarding the best line of chemotherapy in the future. Surgery is however preferred in young women, because radiotherapy causes vaginal stenosis, pyometra, destruction of ovaries and menopause. Preoperative radiotherapy with cisplatin is recommended in endocervical cancer of more than 2 cm, and this shrinks the tumour. Postoperative radiotherapy is useful if surgery has been incomplete or lymph nodes are involved in cancer of the cervix and uterine cancer. Granulosa cell tumour and dysgerminoma are highly radiosensitive and chemosensitive, suited in young women. Choriocarcinoma responds well to chemotherapy which is considered the primary treatment. The limitations and harmful effects of radiotherapy and chemotherapy should be understood. Chemoradiation is also used in residual and recurrent tumours as palliative measures. No alopecia, hydration required Myelosuppression Hypersensitivity, myelosuppression, cardiac arrhythmia, alopecia Drugs Cisplatin Suggested Reading Aalders J. Now considered a metabolic disorder, its prevalence has increased globally and threatens the health of the individual. Once acquired, it is difficult to get rid of, despite dietary control and exercise. It is therefore important to check the growth and weight of adolescents and adults before it creates health problems. Maternal conditions during pregnancy are over-nutrition, glucose intolerance and diabetes, leading to macrosomic fetus. The metabolic changes in this fetus persists through childhood, adolescence and adulthood leading to overweight and obesity. Other factors are as follows: n n Prevalence Increased prevalence over the previous years is due to several factors: n n n n Lifestyle change: Better social and economic environment has changed the lifestyle of people. Lack of exercise due to heavy and prolonged hours at work, physical disability and sedentary life, causing less utilization of calories and accumulation of body fat.
Tumour cell kill by cytotoxic drugs follows the pattern demonstrated by Skipper and Perry (1970) that the killing of tumour cells by cytotoxic agents occurs in an exponential fashion erectile dysfunction medication contraindications cheap 20 mg levitra soft with mastercard, so that a given dose kills a constant fraction of the population erectile dysfunction treatment comparison buy levitra soft with visa, irrespective of its initial size. Prolonged treatment may be necessary to reduce the malignant cell population to a low number which will then be dealt with by the host immune mechanism. Chemotherapy is most effective when it is started early because the number of tumour cell population is low and the rapidly growing and dividing cells are sensitive to cancer chemotherapy. The dose must be so adjusted that maximum destruction of tumour cell is achieved with minimal damage to normal cells. Combination drug regimes and/or sequential drug regimes achieve superior tumour cell control with lowered side effects. Drug resistance may be temporary due to poor vascularity not allowing drugs to reach the tumour cells caused by fibrosis or bulky tumour, or permanent when it is either spontaneous or drug-induced mutation. These drugs damage the cells at any phase of cycle, though dividing cells are most vulnerable. Drugs can be given orally (alkylating agents), intravenously or intraperitoneally at the end of surgery (but are not very effective). Investigations required prior to chemotherapy are: n n n n n n Chemotherapy has advanced tremendously in recent years, and is being increasingly used in the management of gynaecological malignancies. Anaemia, thrombocytopenia, leucopenia Alopecia (reversible) Renal damage Liver damage Cardiac (doxorubicin) Pulmonary (bleomycin) Vagina the metastasis of choriocarcinoma responds to methotrexate and actinomycin-D. Cervix the use of cisplatin concomitant with radiotherapy and prior to surgery in endocervical growth is mentioned in Chapter 38. Plant alkaloids-Vincristine, vinblastine, taxol, docetaxel, etoposide (cell specific)-antimitotic. Newer Anticancer Drugs the development of new chemotherapy improves the disease free interval and prolongs survival. The latter damage the established vessels in the tumour with cediranib 30 mg daily orally, 30% benefit is reported in recurrent epithelial ovarian tumours and fallopian tube cancer. Novel cytotoxic agents (a) Trabectedin (b) Epothilone analogues (c) Topoisomerase 1 inhibitors (d) Pemetrexed (e) Aurora kinase inhibitors Endometrial Cancer Chemotherapy drugs are less used because of poor response in endometrial cancer; surgery and radiotherapy being the cornerstone in its management. Tamoxifen 10 mg bd by its anti-oestrogen action is also effective in advanced stage. Recently, drugs like doxorubicin, platinum, taxane, carboplastin and paclitaxel have been tried. Ovarian Cancer Chemotherapy plays a major role after surgery in the management of ovarian cancer. Today, new drugs with less toxicity improve the survival as well as remission period. Side effects are neutropenia, paraesthesia, scotoma, myalgia, bradycardia, alopecia, vomiting and diarrhoea. Alpha interferon three times a week subcutaneously maintains emission period and improves survival. Corticosteroid and anti-histamine prevent hypersensitive reaction to paclitaxel, thromboplastin and stem cell harvesting. Second-line drugs when woman fails to respond to cisplatin are cyclophosphamide, topotecan, ifosfamide and doxycycline. The woman should be monitored not only for the regression of the disease, but also for myelosuppression, vomiting, diarrhoea, nephrotoxicity, neurotoxicity renal toxicity and fungal infection. Increased birth weight and maintenance of increasing weight through childhood and adolescence. They also retain increased weight gain postpartum, and put on some extra pounds or so following each delivery; multiparae therefore tend to be overweight compared to primis and those with lesser pregnancies. Pathophysiology Bones make up 12% of total body weight, muscles 35% and body fat 27%. Since women tend to accumulate more fat over the abdomen than the hips, as compared to men. Leptin (167 amino acid protein) is a hormone secreted by adipocytes in the fat that influences hypothalamus regarding appetite. In pregnancy, some women develop insulin resistance, and hyperinsulinaemia may be responsible for excessive weight gain through fat deposition and retention of weight gain postpartum.
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